A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain Correct Answer: C. Risk for aspiration Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Place… Read More »
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? A. High fever B. Nonproductive cough C. Rhinitis D. Vomiting and diarrhea Correct Answer: A. High fever If the child has bacterial pneumonia, a high fever… Read More »
A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal? A. Bradycardia B. Decreased appetite C. Exophthalmos D. Weight gain Correct Answer: C. Exophthalmos Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Graves’ orbitopathy (ophthalmopathy) is… Read More »
The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first? A. Notify the physician B. Recheck the O2 saturation level in 15 minutes C. Apply oxygen by mask D. Assess… Read More »
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy? A. Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid C. A small amount of greenish fluid D. A… Read More »
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make? A. “We have a name picked out for the baby.” B. “I need to push when I have a contraction.” C. “I can’t concentrate… Read More »
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is: A. Reposition the monitor B. Turn the client to her left side C. Ask the client to ambulate D. Prepare the client for delivery Correct Answer:… Read More »
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: A. A painless delivery B. Cervical effacement C. Infrequent contractions D. Progressive cervical dilation Correct Answer: D. Progressive cervical dilation The expected effect of Pitocin is cervical dilation. Oxytocin is… Read More »
A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage B. Encourage coughing and deep breathing every 2 hours C. Elevate the head of the bed 30° D. Encourage the… Read More »
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? A. Anticipate the need for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Genupectoral position D. Perform an ultrasound exam Correct… Read More »